Merging P4P and Disease Management: How Do You Know Which One Is Working?

BACKGROUND: An intervention movement in managed care, disease management(DM), is a system of coordinated health care interventions and communication for populations with conditions in which patient self-care efforts are significant.Another managed care intervention movement, pay for performance(P4P), involves an incentive component in which payment is defined based on meeting specific, previously agreed-upon process or outcomes targets. OBJECTIVES: To explore the various characteristics of DM and P4P interventions,determine how they differ, and explore the differences in results of programs in current practice. SUMMARY: In DM, regular ongoing evaluation of clinical, humanistic, and economic outcomes plays a crucial role in reducing costs and improving quality of care. The goal of improving overall patient health in DM is also accomplished by supporting the physician or practitioner/patient relationship and plan of care. P4P initiatives vary more according to the needs and preferences of local providers and plans than do DM initiatives. While DM programs can be implemented without necessarily changing how providers deliver health care, P4P requires new programs and/or systems within the provider sector to improve patient care quality and/or efficiency. P4P initiatives also typically involve the upside or downside risk by physicians/hospitals.Partners HealthCare, based in Boston, features P4P initiatives for inpatient admissions, diabetes, and radiology that have all been met with success. CONCLUSIONS: Both DM and P4P initiatives have been successful in managed care. However, in terms of determining whether DM or P4P initiatives are more effective in improving the quality and efficiency of health care delivery, it is simply too early to tell at this time.

D isease management (DM) and pay for performance (P4P) are 2 recently introduced intervention movements in managed care, designed to improve the collaboration of efforts within the health care system and the resulting patient outcomes. More specifically, DM is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. 1 P4P is typically more variable in its definition, becoming whatever the local providers and plans decide it should be; however, P4P always involves an incentive component in which payment is defined based on meeting specific, previously agreed-upon process or outcomes targets.
Partners HealthCare System (PHS) is a large integrated health care organization in eastern Massachusetts that has been a leader in the P4P movement. One group in the PHS network, Brigham and Women' s Physicians Organization (BWPO), provides health care services to 42,000 patients through its primary care physicians (PCPs). P4P programs exist within BWPO for inpatient admissions, diabetes, and radiology, among others.
The inpatient admissions P4P initiative from BWPO seeks to reduce costs by preventing both unnecessary admissions and admissions to more costly institutions within the network, using a scoring system and through disease management. The P4P program for diabetes aims to improve care by promoting the glycosylated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) screening as well as eye exams for patients with diabetes. The radiology measure employs a computerized ordering system to monitor outpatient testing and promotes peer-to-peer consultation to prevent rising costs through unnecessary tests. Collectively, BWPO' s P4P programs aim to improve the quality and efficiency of care within the organization.
While it is too early to determine if DM or P4P is having a greater effect on care quality or cost-effectiveness, several measures can be taken in the meantime to continue to encourage the movement of these programs in the right direction. Understanding the problems, encouraging informed decision making, focusing on incentives, and creating partnerships with providers and DM vendors are all key actionable items that will improve the chance of success for both managed care quality initiatives.

ss Overview of DM and P4P
Although both are still in their fledgling stages, DM and P4P have shown significant promise in increasing the quality and costeffectiveness of health care in the managed care markets. Both movements are based on the premise of promoting collaboration between all parties in managed care, and both aim to improve patient outcomes while lowering total costs in the long term.
A system of coordinated health care interventions and communications for populations with conditions in which patient Merging P4P and Disease Management: How Do You Know Which One Is Working? Allen L. Smith, MD, MS ABSTRACT BACKGROUND: An intervention movement in managed care, disease management (DM), is a system of coordinated health care interventions and communication for populations with conditions in which patient self-care efforts are significant. Another managed care intervention movement, pay for performance (P4P), involves an incentive component in which payment is defined based on meeting specific, previously agreed-upon process or outcomes targets.
OBJECTIVE: To explore the various characteristics of DM and P4P interventions, determine how they differ, and explore the differences in results of programs in current practice.
SUMMARY: In DM, regular ongoing evaluation of clinical, humanistic, and economic outcomes plays a crucial role in reducing costs and improving quality of care. The goal of improving overall patient health in DM is also accomplished by supporting the physician or practitioner/patient relationship and plan of care. P4P initiatives vary more according to the needs and preferences of local providers and plans than do DM initiatives. While DM programs can be implemented without necessarily changing how providers deliver health care, P4P requires new programs and/or systems within the provider sector to improve patient care quality and/or efficiency. P4P initiatives also typically involve the upside or downside risk by physicians/hospitals. Partners HealthCare, based in Boston, features P4P initiatives for inpatient admissions, diabetes, and radiology that have all been met with success.
CONCLUSIONS: Both DM and P4P initiatives have been successful in managed care. However, in terms of determining whether DM or P4P initiatives are more effective in improving the quality and efficiency of health care delivery, it is simply too early to tell at this time.
self-care efforts are significant, DM emphasizes the prevention of disease as a primary objective. 1 This is accomplished using evidence-based practice guidelines and patient empowerment strategies. In DM, regular ongoing evaluation of clinical, humanistic, and economic outcomes plays a crucial role in reducing costs and improving quality of care. 1 The goal of improving overall patient health in DM is also accomplished by supporting the physician or practitioner/patient relationship and plan of care. 1 P4P initiatives vary more according to the needs and preferences of local providers and plans. Furthermore, while DM programs can be implemented without necessarily changing how providers deliver health care, P4P requires new programs and/or systems within the provider sector to improve patient care quality and/ or efficiency. P4P initiatives also typically involve the upside or downside risk by physicians/hospitals. One characteristic universal to all P4P programs is the concept of granting incentives to providers based on meeting specific, previously agreed-upon process or outcomes targets.

ss P4P at Partners HealthCare System
Based in Boston, PHS is an integrated health system founded by Brigham and Women' s Hospital (BWH) and Massachusetts General Hospital in 1994. 2 PHS includes academic medical centers, community hospitals, specialty hospitals, community health centers, a physician network, home health and long-term care services, and other health-related entities. 2 Within BWPO in PHS, P4P initiatives exist in the areas of inpatient admissions, diabetes, radiology, pharmacy, and electronic medical records. The programs operate by withholding 10% of physician/ hospital fees and returning those fees based on whether quality and efficiency targets are achieved. The inpatient admissions, diabetes, and radiology initiatives are subsequently discussed further.

ss Inpatient Admissions P4P Program
Results of rounding on 50 general medicine admissions at BWH revealed that ~50% of all admitted patients had a chronic illness and a prodrome that precipitated the admission. Furthermore, patients were not always accessing care as early as possible, and many of these admissions may have been prevented with earlier treatment. In order to reduce these costly hospital admissions within network, BWPO designed a medical management program. This program includes the 42,000 lives covered by BWPO PCPs and involves $4.4 million of annual risk, three fourths of which is at stake for BWH and one fourth of which is at stake for BWPO. The program features a numerical rating system that assigns values to different types of hospital admissions and nonadmissions to assess efficiency: One admission to an academic medical center is assigned 1.4, one admission to a community hospital is assigned 1.0, and one observation to any hospital is assigned 0.0. Because academic medical centers are associated with higher costs and are therefore assigned a higher value, the program discourages unnecessary admission to these high-cost centers.
This proactive approach is a good method to address the challenge of unnecessary admissions. Root causes for unnecessary admissions should be understood, but the focus must always remain on the patient. The program must not attempt to reduce all admissions, only those admissions that are preventable. Also, in an attempt to reduce costs, community hospitals and medical observation should be made readily available to the patient when it is clinically appropriate. It is important to maintain a collaborative approach to the problem and thereby prevent duplication of efforts, which only leads to further expenditures.
Preventable admissions for patients with chronic illness can be reduced by improving patient self-management and ensuring that patients see their PCPs earlier in their illness prodromes. 3,4 Improving patient self-management and adherence to medications and therapies can be achieved through patient education (i.e., face-to-face education during hospital stays as well as education administered via follow-up outbound phone calls) and by increasing enrollment and participation in preexisting disease management programs. In order to ensure that patients see their PCPs earlier, patient knowledge about acute symptoms should be strengthened and the perceived or actual barriers to physician access should be removed.
At BWH, a "Plan and Promise" strategy was implemented to promote adherence and develop an illness plan by identifying symptom progression early, presenting patients with a customized strategy to follow, and addressing barriers to access. In order to promote the success of this "plan," the organization "promised" to triage outbound calls from patients and insure timely access to clinicians.
The incorporation of these measures into BWPO' s P4P program has been met with success that can be documented both on an individual level and on a plan level. One patient, a 50-year-old woman with recurrent serious secondary colon infections (Clostridium difficile), had experienced 6 admissions over 3 months. The patient waited before each admission to seek care, leading to the exacerbation of her illness to the point that hospitalization was necessary. Through BWPO' s program, patient education administered by a case manager led the patient to seek care earlier in the course of her subsequent infection, and it was treated before hospitalization was necessary.
Another patient positively affected by BWPO' s program was a 47-year-old male with a history of stroke, diabetes, cardiomyopathy, and atrial fibrillation. The patient was prescribed 17 medications and had multiple emergency department visits and admissions. Further complicating the case, the patient could not afford his medication copays despite working 2 jobs. This patient was referred to a social worker through BWH and received financial assistance for his medication, which ultimately led to improved control over his comorbid disease. He has not been admitted to the hospital since these interventions commenced.
These individual success stories are demonstrative of the type of processes that translate into financial gains for BWH and BWPO, with an improvement in BWPO inpatient withhold return from 66% to 88% between 2005 and 2006 year to date. The financial implications of this are significant because the improved projected 2006 return represents $1 million for BWH and BWPO combined.
ss Diabetes P4P Program BWPO' s diabetes P4P initiative measures and monitors screening rates (A1C, LDL-C, and eye exam) to improve the quality of care among its more than 1,300 patients with diabetes. With $1.1 million at risk for BWPO, the program' s goal is to exceed the 90th percentile in each Health Plan Employer Data and Information Set (HEDIS)-determined measure in each screening category.
The program employs a "centrally guided, locally led" strategy in which a central diabetes patient outreach coordinator tracks data and performance progress while PCP practice staff and PCPs work directly with the patients. Furthermore, electronic records and claims are used to track patient screening data while a central office sends reminder letters with prefilled lab slips to patients. In this hybrid approach to diabetes care, an outreach coordinator provides monthly "out-of-compliance" reports to practice staff, who call patients to schedule appointments. In addition, phlebotomists make home visits, and incentives and celebratory rewards are given to PCPs, ophthalmologists, and staff.
BWPO' s diabetes P4P program demonstrated consistent improvement over a 3-year span in terms of screening rates for A1C, LDL-C, and eye exams. Between the years of 2002 and 2005, screening rates for A1C improved from 67% to 93%, screening rates for LDL-C improved from 78% to 94%, and eye exam rates improved from 54% to 67% (Figure 1), all of which met the P4P targets.
Upon reviewing the characteristics of BWPO' s diabetes P4P program, it may appear that the initiative could actually be considered DM. The program does, in fact, share many characteristics with a typical DM program, including the support of physicians in executing a plan of care, the use of similar record or claims data, and the importance of patient communication. However, BWPO' s diabetes P4P program differs from DM programs in that it relies on a direct relationship with PCP practices, whereas DM programs have limited interaction with PCP practices. Furthermore, the diabetes P4P program incorporates the use of incentives for PCPs, while the DM program does not.

ss Radiology P4P Program
The radiology P4P program at BWPO is based on the concept of evidence-based medicine for imaging. In order to improve patient safety, quality, and efficiency of care, the radiologist serves as a physician consultant, both before and after testing, thus fostering appropriate use of radiology services. The program includes the 42,000 patients seen by BWPO PCPs and involves $2.2 million at risk, 80% of which belongs to BWH and 20% of which belongs to BWPO.
The radiology measure looks at outpatient testing rates per 1,000 patients for magnetic resonance imaging (MRI), computed tomography (CT) scan, and nuclear cardiology. A computerized physician order entry (CPOE) system is in place to aid in the ordering of imaging services, and the CPOE system is integrated into the electronic medical records system to prevent duplicate or unnecessary testing. Decision support and peer-topeer consultation also reduce the likelihood of unnecessary testing, and physician profiling helps program leaders target specific physicians for intervention.
The radiology P4P program appears to be demonstrating success, with more and more physicians embracing the CPOE system. While only a fraction of physicians used the system in October 2002, by August 2004, the number of patients tested via CPOE was approaching 75% of total patients with a radiologic exam ( Figure 2). This program shares many characteristics with prior authorization programs being utilized by other health plans to reduce unnecessary radiology testing; however, a major difference with the BWPO approach is that it is integrated into the electronic ordering system and involves local peer-to-peer interaction rather than communicating with personnel from a third-party vendor.
ss Conclusions BWPO' s P4P programs aim to improve the quality and efficiency of care within the organization through local efforts and central guidance. While these programs share several characteristics with DM programs, they all differ in their methodology.
In terms of determining which of the 2 types of programs are the most effective in improving the quality and efficiency of health care delivery, it is simply too early to tell at this time. In the meantime, several measures can be taken to ensure that both the DM and P4P initiatives are successful in achieving their goals. Understanding the problem being targeted is imperative, as is emphasizing disciplined decision making before initiating a program and excellent implementation efforts. A focus on incentives and partnership between providers and DM vendors, where possible, may further increase the likelihood of program success. Finally, assumptions should be questioned periodically and external review welcomed to ensure progression of these initiatives in the right direction. The DM and P4P movements are likely to grow in the future, parallel to the growth in the demand for improved quality and efficiency of care. The federal government may further the development of these movements by pushing for P4P and possibly DM for Medicare and other public sector programs, but if they do so, it will most likely be on a very tight budget. Stakeholders should be cognizant of excessive hype and the "creative" use of statistics to justify various DM and P4P initiatives, as this will increase confusion about what really works.
The improvement of health care quality is a complex problem with many facets and, as such, there will be no panaceas. Comprehensive efforts featuring multiple components and coordinated efforts, however, have shown promise. Technology, such as electronic medical records, will assist in these efforts, provided there is sufficient leadership, systems, and incentives to effect measurable change. Privacy concerns will also remain an issue and should be addressed to prevent the misuse of protected information. Although cooperative, multistakeholder solutions are challenging to develop and maintain, they will likely be met with success in the improvement of health care quality once in place.